ABSTRACT

SCHMALBACH, L.A. F r wheelchairs, MS in Special Physical Education. August 1996,47pp. (P. Diocco)

The purpose of this study was to determine firctors that predispose injuries in athletes who compete &om a wheelchair. Athletes competing in basketball, tennis, bowling, quad rugby, and track aud field were mailed questionnakes. One hundred and eleven (91M, 20F) responses were obtained. The average age of the athletes was 32.33 f 9.19 and they had been competing for 8.22 f 5.62 years. ANOVA was used to determine if the number of minor or significant injuries diiered between sports. Results show that basketball players experienced a higher number of minor injuries than tennis players or bowlers. ANOVA was used to detemine if body mass index (BMI), gendel; coaching, and competitive years had an effect on the total number of injuries received during a 2 year period. No significant differences were found. In summary, the prevalence of minor injuries in basketball players when compared to tennis players and bowlers was significantly higher. Other trends were noted when looking at how BMI, competitive years, and coaching impacted on the total number of injuries reported. Further studies are needed before conclusions can be drawn in these areas.

FACTORS THAT PREDISPOSE INJURIES IN

ATHLETES WHO UTILIZE WHEELCHAIRS

A MANUSCRIPT STYLE THESIS PRESENTED

THE GRADUATE FACULTY

UNIVERSITY OF WISCONSIN-LA CROSSE

IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE

MASTER OF SCIENCE DEGREE

BY

LISA ANN SCHMALBACH

AUGUST 1996

COLLEGE OF HEALTH, PHYSICAL EDUCATION, AND RECREATION

UNIVERSITY OF WISCONSIN-LA CROSSE

THESIS FINAL ORAL DEFENSE FORM

Candidate: L m

We recommend acceptance of this thesis in partial llfillment of this candidate's requirements for the degree:

W e r of Science in Swial Phvsical Education

The candidate has successhlly completed the thesis final oral defense.

Thesis Committee Chairperson Signature

7//5/96 Th4s Committee ~ & b e r Signature /D&

This thesis is approved by the College of Health, Physical Education, and Recreation.

7-2- </ 9 6 -ate Dean, c&e of Health, Date Physical Education, and Recreation

ACKNOWLEDGMENTS

I would like to express my sincere thanks to the following people for their help and

dedication in the completion of this study.

To Dr. Patrick D~ROCCO, for the time and patience during this past year. Thank

you for taking the time to give me the guidance and desire to complete this study. Your

efforts are greatly appreciated.

To Mark Gibson, for the support and knowledge that you provided me during this

year. You have helped to make this year a very successfid one in my life. I would also

like to thank the rest of the Gibson family, Barbara, Kelli, Kyle, and especially Katherine,

for making my stay in Lacrosse extra special. I will never forget everything you have

done for me. You are a wonderfbl family.

To Dr. Karen Palmer McLean, for all of your input and knowledge during the

completion of this thesis. The ideas and suggestions you provided proved to be invaluable

during the completion of this study. Thank you also for your help with the statistics.

To Dr. Dennis O'Brien, for all for his help with the statistical section of this paper.

Thank you so very much.

To all of my fiends for putting up with me and for never losing faith in me. I

couldn't have done this without you.

Finally, to my family, especially my Mother and Father, for their wntin~~al support,

and for always believing in me. Thank you for all of your love. I dedicate this research

project to you.

TABLE OF CONTENTS PAGE

LIST OF TABLES .............................................................................................

LIST OF FIGU'RES ...........................................................................................

...................................................................... LIST OF APPENDICES .i ............

.................................................................................. INTRODUCTION

........................................................................................... METHODS

...................................................................................... Subjects

.......................................................................... Instnunentation

...................................................... Questionnaire Administration

.......................................................................... Analysis of Data

.............................................................................................. RESULTS

.................................................................................... Subjects

S w e y Results ...........................................................................

Question One ..............................................................................

............................................................................. Question Two

........................................................................... Question Three

........................................... Question Four ...-...... ......................

........................................................................... Question Five.,

Question Seven ...........................................................................

iii

vi

vii

Question Eight ............................................................................

........................................................................................ DISCUSSION

Minor Injuries ............................................................................

..................................................................... Significant Injuries

................................................................................... Coaching

. . ..................................................................... Cornpetitwe Years

Body Mass Index .......................................................................

...................................................................................... Gender

................................................................................... CONCLUSIONS

..................................................................... Recommendations

REmRENCES ......................................................................................

APPENDICES ......................................................................................

PAGE

18

18

21

22

22

23

24

25

25

25

27

29

TABLE

LIST OF TABLES

PAGE

1. Descriptive characteristics of subjects by sport ...................................... 8

2. The relationship between significant injuries and the number of years of . . competItIon among sports ................................................................... 15

3. The relationship between minor injuries and years of competition among sports .................................................................................................. 16

LIST OF FIGURES

FIGURE PAGE

....................... 1 . The number of athletes who responded fiom each sport 9

2 . Injury rate for competitive levels by sport ............................................ 11

.......................................... 3 . Mean sigdicant injuries reported by sport 13

.................................................. 4 . Mean minor injuries reported by sport 14

5 . The number of injuries reported by athletes who trained with a coach and those who trained without a coach ................................................ 17

.................. 6 . Injury rate as reported by BMI clasiification for each sport 19

7 . Injury rate its reported by gender for each sport ................................... 20

LIST OF APPENDICES

APPENDIX PAGE

A. ATHLETIC INJURY QUESTIONNAIRE ........................................... 29

B. COVER LETTER ................................................................................ 33

C. REVIEW OF RELATED LITERATURE 35 ............................................

INTRODUCTION

Wheelchair basketball was the first organized sport for persons with disabiities.

Several basketball organizations were formed as early as 1945. In 1949, America had its

first National Wheelchair Basketball Tournament. In 1952, Sir Ludwig Guttmann

organized the first international sporting event for persons with paralysis, The Stoke

MandeviEs Games. In 1956, the National Wheelchair Athletic Association was established

jf chaefer & Proffer, 1989). Today, this organization is known as Wheelchair Sports,

USA, and governs 14 regions in the U.S. with 40 states represented.

By 1986,4,000-5,000 athletes with disabilities were competing in organized sports

(Monahan, 1986). With participation becoming more com~&~t~ve, researchers began to

look at injuries incurred by athletes who utilize a wheelchair. Bloomquist (1986) stated

that "While athletes with disabiliiies may not be injured any more than the able-bodied, the

types of injuries they sustain are specitic to their disabiities and sports" @. 97). Studies

have traditionally examined what types of injuries occur with athletes who use a

wheelchair. Current studies are focusing on the factors that predispose one to these

injuries.

In 1984, George Murray was the first athlete who uses a wheelchair to be pictured

on the cover of a Wheaties box (Monahan, 1986). Since then, public awareness of sports

for individuals in wheelchairs has increased. With this increase in awareness, doctors,

athletic trainers, coaches, and athletes need to be educated on the potential risks for injury

and how these risks can be minimized.

1

Numerous researchers and authors have examined the injuries incurred by athletes

who use wheelchairs during training and competition (Bloomquist, 1986; Ceccotti, 1984;

0.1rtiq 1982; Curtis & Dillon, 1985; Fmara et d., 192; Ferrara & Davis, 1990,

Eoeberigs, Debets-Eggen, & Debets, 1990, Martinez, 1989; McCormick, 1985; Taylor &

Williams, 1995; Weiss, 11986). These studies examined the frequency of injuries found in

athletes who compete from a wheelchair, and how these injuries can be prevented.

However, only Taylor and Williams (1995) have examined the factors that predispose

athletes to these injuries and the patterns associated with these injuries. Their study

focused on British wheelchair racers. More sports need to be included for a more

generalized picture to emerge. Ferrara and Buckley (1996) conducted an epidemiological

study to develop a research tool to help identify trends and patterns in athletes who

compete in a wheelchair. They developed the first comprehensive surveillance study of

injuries that occur in sports for athletes who compete in a wheelchair. Ferrara and

Buckley (1996) concluded that the injury rate resembles those reported for other athletic

populations. They also concluded t h t more research needs to be conducted to determine

patterns of injuries and prevention effectiveness.

Research is needed to determine if there are patterns or trends in various

wheelchair sports injuries. Athletes who compete fiom a wheelchair need the best

possible information to modify their equipment and/or training techniques in order to

decrease the number of sport-related injuries they incur.

i

I

The purpose of this study was to examine the factors that predispose athletes who

compete from a wheelchair in the sports of basketball, quad rugby, bowling, tennis, and

track and field to injuries. These sports were chosen to represent high and low risk sports

as classified by Curtis and Dillon (1985). The results of this study will benefit the many

individuals with physical disabiities who are participating in competitive sports as well as

the coaches, athletic trainers, and physicians who work with them.

METHODS

Subiects

The sample in this study represented current athletes in basketball, quad rugby,

tennis, bowling, and track and field. Subjects surveyed ranged in age from I8 to 50 years

of age. Packets containing questionnaires were sent to various organizations who in turn

mailed them to various athletes. These organizations included several college and local

teams, Wheelchair Sports USA, Paralyzed Veterans Association, American Wheelchair

Bowliig Association, and the National Wheelchair Tennis Association. From each of the

I five sports, a minimum of 30 athletes were sent questionnaires. This number was

I detennined using a power analysis at the 80% power level with .05 significance for a two-

tailed design, with a medium effect size of 0.50 (Kr~emer, 1987).

A total of 330 questionnaires were mailed to dierent athletes. A number coding

system was used to protect the confidentiality of the participants' responses. If an athlete

indicated participation in more than one sport, a response was recorded for each sport in

which the athlete participated. The data could be separated this way due to the fact that

each injury was classified by the sport in which it occurred.

Instrumentation

A questionnaire was developed focusing on the subject's disability, frequency of

trainin& injuries acquired within the last 2 years, recoveiy t im for each injury, medical

treatment received relevant to the injury sustained, and time missed from competition or

training due to the injury. The injury reporti~lg system used was modeled from a

questionnaire published by Curtis (1982).

Ouestionnaire Administration

Questionnaires (see Appendii A) were mailed along with a cover letter (see

Appendix B) and a stamped, addressed envelope to the sample population. A response

time of 2 weeks was given in the cover letter and on the questionnaire. After 3 weeks, any

athletes who had not yet returned their questionnaires were sent mother stamped,

addressed envel~pe with an additional questionnaire. lfthe second survey was not

returned during the foilowing 3 weeks, a personal telephone call from the investigato: was

used to elicit a response. If no phone number wms available, a postcard was sent

reminding the participants that questionnaires had not yet been returned. Many of the

cooperating organizations did not release the names and addresses of the athletes who

were mailed the questionnaires, thus, follow-up occurred on only 15% of the

questionnaires that were initially mailed.

halvsis of Data

To quantify the information received from the questionnaire, percentages and

frequencies were used. Each question was evaluated by responses, and expressed in a

percentage or frequency.

The following questions were answered from the data collected. SPSS for

Widows 6.0 was used to analyze the dsta.

1. Do the number of years of competitionltraining affect the number of total

injuries received during a 2 year period? An injury is defined as "Any trauma

to the participant that occurred during any practice, training, or competition

session that caused the athlete to stop, limit, or mode participation for one

day or rnore" (Ferrara et al., 1992, p. 184). A Pearson product correlation was

used to determine if there was a relationship between the total number of years

of competition and the number of injuries. If a relationship existed, the data

were divided into three levels based on years of competition. The levels were

as follows: beginner (0-2 years), intermediate (2-5 years), and experienced (5+

years). A two-way ANOVA (sport x level) was then used to determine

significance.

Do the number of signiiicant injuries received diier between sports?

Signiiicant injuries include all traumata with time loss greater than 7 days

(Buckley & Powell, 1982, p. 280). A one-way ANOVA was performed to

3. Do the number of minor injuries diier between sports? A minor injury

constitutes a reportable injuryfiess which did not prevent the athlete from

returning to effective participation within 1 week from the day of onset

(Buckley & Powell, 1982, p. 280). A one-way ANOVA was used to

determine significance.

4. In each sport, do the number of years of competition affect whether the athlete

experiences more significant injuries? Five one-way ANOVA'S (one for each

sport) were performed using the three levels described in question one.

5. In each sport, do the number of years of competition affect whether the athlete

experiences more minor injuries. Five one-way ANOVA's (one for each sport)

were performed using the three levels described in question one.

6. If the athlete trrrins with a coach, are the number of injuries received affected?

A two-way ANOVA was used (sport x coach).

7. Does the body mass index @MI) of an athlete play a major role in the number

of total injuries received? This was analyzed using a two-way ANOVA (sport

x BMI level). BMI was divided into three levels as established by Rimmer

(1994). These levels are as follows: underweight (< 2 1 0 , C 24(F)), average

(2 21 to s 2 7 . 9 0 , 2 24 to s 33.9(F)), and overweight (2 2 8 0 , 2 34(F)).

8. Does gender play a role in the number of total injuries during a 2 year period?

SignZcance was determined by using a two-way ANOVA (sport x gender).

RESULTS

Subiects

Sixty questionnaires were returned for a return rate of 18.18%. Eighty-seven

percent of the respondents reported competing in more than one sport. As stated in the

procedures, injuries were reported by the sport in which they occurred. This reporting

resulted in a rota1 of 1 1 1 responses. Ninety one males (82%) and 20 females (18%)

represented the 1 1 1 responses. Characteristics of the subjects are presented in Table 1.

The subjects ranged in age from 18 to 49 years. On average, the respondents had been

competing in wheelchair athletics for 8.22 f 5.62 years. The number of athletes who

responded from each sport is presented in Figure 1. Track and field and basketball

represented over 60% of all respondents.

Survev Results

The results of this study showed that 57% of all injuries reported were soft tissue

injuries. This supports Curtis and Dillon's (1985) findings that soft tissue injuries are the

most commonly reported injuries by athletes who use a wheelchair. Abrasions and

lacerations accounted for 19% of all injuries, while blisters accounted for 17% of the

injuries reported.

Eighty-two percent of the respondents had an acquired disability. Of these, 82%

had competed in competitive athletics before the onset of their disabiity. Seventy-nine

percent of the respondents utilized their wheelchair to ambulate outside of their respective

sports.

Table 1. Descriptive characteristics of subjects by sport

Sport N Age BMI Competitive Years Minor Jqbries Significant @juries

M SD M SD - M SD M SD M SD

Basketball 32 28.48 8.41 24.92 5.31 7.77 5.42 1.42 1.75 .30 .53

Track& Field 35 32.71 8.49 24.37 5.50 8.12 5.43 1.00 1.33 -34 .91

Tennis 16 34.38 9.57 23.98 5.61 8.36 4.80 .25 .58 .SO .89

Bowling 12 37.58 11.29 25.50 4.13 12.54 7.34 .25 .62 -08 .29

QuadRugby 15 33.53 8.02 24.65 6.36 5.86 4.49 .40 .63 -40 .74

All sports 111 32.33 9.19 24.64 5.38 8.22 5.62 .86 1.34 .33 .73

I female 1

Figure 1. The number of athletes who responded from each sport

When looking at the vaining practices of the respondents, 46% of the athletes

trained either 2 days (23%) or 6 days (23%) per week. A total of 19% of the athletes

trained 5 days per week while 18% trained 3 days per week. When breaking down

training into hours per week, 34% of the athletes that responded to the questionnaire

trained &om 2-6 hours per week. Close behind, at 27%, were the athletes who trained for

10-15 hours per week. Eighty-seven percent of the athletes thatcesponded to the

questionnaire reported participating in more than one sport. Therefore, training practices

could not be broken down into sport.

Sports medicine services available to the athlete were also determined. Thirty-two

percent of the respondents had no sports medicine services available for their use. Of the

remaining 68%, physical therapists were utilized the most (76%), followed by medical

doctors (64%) and athletic trainers (40%).

Ouestion One

To answer question number one (Do the number of years-of competitiodtraining

affect the number of total injuries received during a 2 year period?), a Pearson correlation

coefficient was calculated. The correlation coefficient between taal injuries received and

years of competition was 6.274. Therefore, only 7.5% of the variabiility of total injuries

received is consistently associated with the variability in years of competitiodtraining, or

vice versa. Since the correlation was quite low, the two-way A W A (sport x levels)

was not performed. The injury rate for each competitive level bgsport is depicted in

Figure 2.

intermediate

Figure 2. Injury rate for competitive levels by sport

Ouestion Two

A one-way ANOVA was used to answer question two: Do the number of

significant injuries d v e d differ between sports? The results revealed no significant

ditbence (f ratio = 0.598; p value = 0.665) concerning the number of significant injuries

incurred between sports. Mean significant injuries reported by sport are depicted in Figure

3.

Ouestion Three

Question three (Do the number of minor injuries received differ between sports?),

was answered using a one-way ANOVA. The results show that there is a significant

difference (f ratio = 3.798; p value = 0.006) between sports concerning the number of

minor injuries received. A Tukey-b post-hoc analysis showed that there is a significantly

higher incidence of minor injuries received in basketball competition than in tennis and

bowling (see Figure 4).

Ouestion Four

Five one-way ANOVA'S were performed to answer question four (In each sport,

do the number of years of competitionltraining affect the number of significant injuries?).

There was no significant difference among the three levels in any particular sport (see

Table 2).

w

Figure 3. Mean significant injuries reported by sport

Figure 4. Mean minor injuries reported by sport

Table 2. The relationship between significant injuries and the number of years of competition among sports

sport F ratio p value

Quad Rugby 0.9707 0.4067

Track & Field 1.4084 0.2593

Tennis 0.1492 0.8629

Basketball 0.4812 0.6227

The respondents from the sport of bowling could not be divided into levels to

determine whether the years an athlete has been competing had an impact on the total

number of injuries received. There was one beginning athlete while the rest were classified

as experts.

Ouestion Five

Five one-way ANOVA's were performed to determine if the number of years of

competitionltraining affected the number of minor injuries in each sport. There was no !

1 significant difference among any of the levels in any sport (see Table 3). Bowling ewld

not be analyd because there were no intermediate athletes.

Table 3. The relationship between minor injuries and years of competition among sports

F ratio p value

Quad Rugby 0.8339 0.4580

Track and Field

Tennis

Basketball 1.2793 0.2930

Ouestion Six

I A two-way ANOVA (sport x coach) was used to determine if the number of

I injuries differ between athletes who train with a coach and those who do not. The

1 interaction between coach and sport (f d o = 0.189; p value = 0.943) and the main effect

I of having a coach (f ratio = 0.009; p value = 0.925) were not significant. However, there

I was a significant main effect for sport (f ratio = 2.641; p value = 0.038) in the total

number of injuries received. A Tukey-b post-hoc analysis revealed that there were more

injuries received in basketball than bowling. The raw data for injuries reported by athletes

who trained with a coach and athletes who did not train with a coach are shown in Figure

5.

Figure 5. The number of injuries reported by athletes who trained with a coach and those who trained without a coach

Ouestion Seven

A two-way ANOVA (sport x BMI level) was used to determine if the body mass

index of an athlete played a role in the number of total injuries received. Neither the

spodBMI i n t d o n (f ratio = 0.810; p value = 0.596) or the main effects of sport (f

ratio = 1.914; p value = 0.114) or BMI classification (f ratio = 0.164; p value = 0.849)

were signEcant. The raw data of injury rate by BMI classification are depicted in Figure

Ouestion Eight

To detennine if gender had an impact on the total number of injuries received, a

two-way ANOVA (sport x gender) was calculated. Neither the sport (f ratio = 1.3 16; p

value = 0.269) or gender (f ratio = 0.052; p value = 0.820) main effects or the interaction

(f ratio = 0.952; p value = 0.437) were significant. The I-aw data of the injury rate by

gender are shown in Figure 7.

DISCUSSION

The purpose of this study was to examine factors that predispose athletes that

compete fiom a wheelchair in the sports of basketbally quad ~ g b y , tennis, bowling, and

track and field to injury. As a result of this study, several questions were answered

concerning the factors that may cause injury and the frequency of injuries among the five

sports.

underweight average

Figure 6. Injury rate as reported by BMI classification for each sport

male

Figure 7. Injury rate as reported by gender for each sport

The results showed that there was a significant difference in the number of minor

injuries reported by athletes in different sports. Athletes competing in the sport of

basketball experienced a sigdtlcantly higher number of minor injuries during a 2 year

period than did tennis or bowling athletes. According to Curtis and Dillon (1985),

wheelchair basketball is the second highest risk sport, second only to road racing. This

high risk of injury may be a contributing factor in the increased number of minor injuries

incurred by basketball players.

Another factor contributing to the higher incidence of minor injuries among

basketball players is the bt that basketball is a contact sport while tennis and bowling are

considered noncontact. Competing in a contact sport increases the chance of colliding

into another player or obstacle which may then lead to injury. Tennis and bowling are

individual sports, whereas basketball is a team sport. The number of athletes on a playing

surface at one time is increased for basketball. The greater number of players on a playing

surface increases the potential for injury due to contact.

Even though athletes fiom track and field did not experience a significantly greater

number of minor injuries during a 2 year period than tennis and bowling athletes, the total

mean number of minor injuries was considerably high. When looking at the types of minor

injuries track and field athletes reported, the most common injuries were blisters,

abrasions, and soft tissue injuries. These injuries were most likely a result of the demands

of the sport.

Significant In-iuries

The number of significant injuries reported during a 2 year period were not

statistically different among sports. However, when looking at the raw data, the

investigator feels that these numbers are rather high. For the sports of tennis, quad rugby,

track and field, and basketball, sigdcant injuries represented at least 30% of all injuries

incurred during a 2 year period. Reducing the number of significant injuries by just one

can make a difference in the performance of an individual or team. The majority of these

injuries were sofi tissue in nature resulting in more than 7 days lost from practice or

training. Several ihctures were also reported due to fds. These injuries may be avoided

by evaluating the technique and practices of these athletes. By avoiding these injuries, one

may have more time to practice, leading to a greater chance for a success!kl season.

Coachina

The total number of injuries reported did not differ significantly between athletes

who trained with or without a coach. The results showed that athletes who trained with a

coach in bowling and tennis tended to experience fewer injuries that those who did not

train with a coach. This decrease in the total number of injuries may be due to proper

fom and techniques that can be taught by the coach. Athletes who train with a coach also

have supervision and guidance during practice and competition. A coach may be able to

detect a minor injury early so that it may be properly treated before it becomes a major

problem for the athlete.

On the other hand, the athletes competing in the sports of basketball, quad rugby,

and track and field who trained with a coach reported a higher incidence of injury than

athletes who did not train with a coach. One reason for this trend is that very few

respondents fiom the sports of basketball, quad rugby, and track and field reported

training without a coach. The majority of the respondents trained with a coach, therefore,

the number of total injuries is high. Further studies are needed to determine if training

with a coach has an impact on the number of injuries among these athletes.

Competitive Yearq

The number of years an athlete competed did not significantly affect the number of

total injuries received during a 2 year period. The athletes were grouped into three levels

based on the number of years of competition: beginner (0-2), intermediate (2-S), and

expert (5+). Although the results were not statistidy significant, there was a general

trend for the number of total injuries to increase as the level of competition years increased

in the sports of basketball, quad rugby, track and field, and tennis. Expert athletes

reported a considerably higher number of injuries than did beginning and intermediate

athletes. Intermediate athletes reported a higher number of total injuries than did beginner

athletes.

One possible explanation for this trend may be that the longer one competes in a

particular sport, the more comfortable and familiar that athlete becomes with that sport.

This familiarity and comfort may challenge the athlete to try new and more difficult

techniques. These new techniques may involve more risks which may potentially lead to

more and d i f fmt types of injuries.

Another possible explanation for this trend may be that as one becomes

experienced and skilled in a sport, one's intensity of training increases. With an increased

training intensity athletes may be pushing their bodies to limits that may produce injuries.

Bodv Mass Index

In reporting body mass index (BMI), the athletes were grouped as underweight,

average, or overweight (Rimrner, 1994). The athletes in basketball and tennis had

an injury rate that fell within a normal distributian. Athletes withaverage BMI

experienced a higher injury rate than did those in underweight and overweight BMI.

Quad rugby, track and field, and bowling, however, reported a higher injury rate in

the underweight BMI rather than the average BMI. An underweight individual may

experience more injuries due to the decreased body mass combined with the demands of

the sport.

Normative BMI values have not been established for populations with physical

impairment, particularly following spinal cord injury. It may be that a BMI classified as

underweight by nonns developed on populations without disabilities would be normal for

populations following spinal cord injury where significant muscle atrophy and loses of

bone mineral density contributes to a much lower weight relative to height.

Gender

Gender did not sect the total number of injuries reported. However, these results

should be interpreted with caution as the sample size for females was quite small. When

looking at the raw data of the types of injuries received, no differences were found

between males and females. Further studies of gender and injury rate need to be

conducted;

CONCLUSIONS

In conclusion, basketball players experienced a significantly higher incidence of

minor injuries in a 2 year period than did tennis and bowling athletes. The number of

significant injuries received during a 2 year period did not differ significantly across sports.

The study also revealed that body mass index and gender had no significant impact on the

total number of injuries received across sports. The number of years an athlete has been

competing had no significant effect on the total number of injuries. However, there did

seem to be a trend for more experienced athletes to experience more injuries.

Recommendations

Based upon the results of this investigation, the following are recommended for

future study:

1. A similar investigation should be performed using larger and more equal

sample sizes among sports.

Rationale: Significant differences among sports may be found if larger and

more equal sample sizes are obtained, There is a greater chance for differences

to emerge when the sample size is larger.

2. A similar investigation should examine sports other than basketball, bowling,

tennis, quad rugby, and track and field.

Rationale: The curcent study can only be generalid to the sports of

basketball, quad lugby, tennis, track and field, and bowling. With the

continuing popularity of sports for individuals who utilii a wheelchair, other

sports need to be examined so athletes can receive the best training and

care that is available to them.

3. An investigation should be conducted to detennine the validity of measuring

body mass index (BMI) in individuals with spinal cord injury.

Rationale: The validity of BMI has yet to be established for persons with spinal

cord injury. Conclusions and recommendations can not be made from this

study concenling BMI until it is validated for this population.

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Martinez, S.F. (1989). Medical concerns among wheelchair road racers. The Phvsician and Sportsmedicine. 17(2), 63-68.

McConnick, D.P. (1985). Injuries in handicapped alpine ski racers. The Physician and Smrtsmedicine. 13(12), 93-97.

Monahan, T. (1986). Wheelchair athletes need special treatment - but only for . . injuries. The Phvsl- Sportsmedicine. 14(7), 121-128.

Rimmer, J.H. (1994). mess and rehabiitation p- lation Madison, WI: Brown & Benchmark.

Schaefer, R.S., & Proffer, D.S. (1989). Sports medicine for wheelchair athletes. h e r i c a n Familv Phvsician. 39(5), 239-245.

Taylor, D., & Williams, T. (1995). Sports injuries in athletes with disabilities: Wheelchair racing. Parapl- 296-299.

Weiss, M. (1986). Carpal tunnel syndrome and other peripheral nerve problems in wheelchair sports. Two Bounce News. 7(4), 20-21.

APPENDIX A

ATHLETIC INJURY QUESTIONNAIRE

30

ATHLETIC INJURY OUESTIONNAIRE

The purpose of this questionnaire is to determine any patterns that occur in athletic injuries, and to determine fictors that may contribute to these injuees. Please complete the questionnaire to the best of your knowledge.

1. Male Female (please check)

2. bee 3. Height (inches) 4. Weight

5. How many years have you been competing in wheelchair sports?

6. Is your disabiity congenital (fiom birth)? (please check) - Y= no

*If you answeredyes, rrd-to question #9.

7. How many years have you been disabled?

1 8. Did you participate in competitive sports before the onset of your disability? (please

i check) - Yes - no

9. For our purposes, would you please explain, in detail, your disability. (ex.: spastic CP - hemiplegia, etc.)

10. Please check the sports that you currently compete in or are training for competition. (check all that apply)

basketball - - quad rugby tennis - - track field events - - bowling

11. Average number of days you train during the week. (includes fitness and sport speci6c) (please check) 0-1 day 2 days 3 days 4 days -5 days 6 days - 7 days -

12. Average number of hours you train per week. (please check) 0-2 hours 2 - 6 hours 6 - 1 0 hours 1 0 - 15 hours -1 5-20 hours 2 0 + -

13. Do you train with a coach? j e s n o (please check)

15. What sports medicine services are available to you? (please check) - Athletic trainer - Medical doctor - Physical therapist - Sports medicine clinic - No services available

16. Do you use a wheelchair to ambulate outside of your sport? - yes - no (please check)

17. If you have received an injury within the past two years due to competition or training, please complete the following grid u s i i the codes for injury type, body area, sport, time lost, treatment, and injury mechanism. Treat each injury as a separate injury (ex: (1) blister in basketball, (2) blister in tennis).

INJURY CODES BODY AREA CODES SPORT CODES

1-Abrasion or lacemtion 2-Back injury 3-Blisters 4-Bursitis S C o U o n 6-Dislocation 7-Fracture 8-Muscle pull 9-Pressure sore 10-Spinal injury 1 I -Sprain or seain 12-Temperature regulation

disorder (hot or cold) 13-Tendonitis 14-<)tber 15-Otber

(please state)

A-Head and neck B-Shoulder C-Elbow and forearm D-Hand and wrist E-Fingers and thumb F-Back G-Hips H-Lower extremities

TIME LOST CODES

I--7 days It-8 or more days

INJURY MECHANISM

A-Acute (sudden onset) CColiision R C h n i c (gradual onset) S-Spill or fall

BAS-Basketball BOW-Bowling --Field events QRQuad~gby TR-Tmck events & road races TEN-Tennis

TREATMENT CODE

AT-Athletic trainer MD-Medical doctor NT-No treatment sought FT-Physical Therapist OTHER

@lease state)

18. Do you wear protective gear, or have you made equipment modifications as a result of any of the above listed injuries? (please check)

Y e s no - 19. If you answered yes to question 18, describe what protective gear or modifications

you have made.

19a. Who made the protective gear?

- Please check here if you would like a copy of the results and findings sent to you upon completion of this study.

If you would like a copy of the results, please provide your name and address below.

Please return by May 15, 1996

Thank you for your time!!

APPENDIX I3

COVER LETTER

May 1,1996

Dear Athlete:

I hope this letter finds everything going well. With the increased participation in sports for people who utilize a wheelchair, there is an ongoing need for researchers to examine the injuries that occur in athletes who utilize a wheelchair. As a graduate student at the University of Wisconsin-Lacrosse in Special Physical Education, I plan to conduct a study that will develop a detailed description of patterns that occur with injuries in competitive athletes who utilize a wheelchair. I will also look at the factors that contribute to these injuries.

The purpose of this letter is to recruit you to be a participant in this study. Enclosed you will 6nd an athletic injury questionnaire. The questionnaire will take approximately 15-20 minutes to complete. All responses given on this questionnaire will remain confidential. Only the chief investigator will be able to identifjl your individual responses. Any data that is referred to in this study will be group data only. Filling out this questionnaire will give the researcher the permission to use all information for the sole purpose of this study.

The resulting information from this study will help contribute to the knowledge base for training and the rehabilitation of athletic injuries. Once the results of the study have been gathered and analyzed, I will be happy to supply you with a summary of the findings. I hope you will h d time to participate in this study. Thank you in advance for your time and participation. Please return the questionnaire in the envelope provided on or before May 30, 1996.

Sincerely,

Lisa Schmalbach Chief Investigator

Dr. Patrick Diocco Director Special Physical Education (608) 785-8695

Enclosures: questionnaire (3), return envelope

APPENDIX C

REVIEW OF RELATED LITERATURE

REVIEW OF RELATED LITERATURE

The review of related literature has been divided into three sections: injuries to

wheelchair athletes, general prevention of injuries, and sport specific research. The

injuries to wheelchair athletes section includes information on prevalence, cause, and

prevention. The general prevention section includes information that will aid in all areas

of prevention. Lastly, the section on sport specific research discusses research conducted

on specific wheelchair sports.

Injuries to Wheelchair Athletes

Soft Tissue Iniurie

Soft tissue injuries, including muscle-pulls, strains, sprains, bursitis, and tendonitis,

are the most commonly reported injuries by athletes who use a wheelchair (Bloomquist,

1986; Ceccotti, 1984; Madorsky & Curtis, 1984). Curtis and Dillon (1985) found that

33% of all injuries reported were soft tissue injuries. Many of these injuries were chronic

injuries that the athletes tended to themselves. Ferrara and Davis (1990) reported similar

findings. They found that 48% of injuries that occurred during a one year period to elite

athletes who use a wheelchair were soft tissue injuries.

There are many causes of soft tissue injuries: overuse of muscles, falls or spills,

physical contact, and lack of proper technique and training (Bloomquist, 1986; Madorsky

& Curtis, 1984). Many of these injuries can be prevented by proper wann-up and cool-

down procedures, appropriate stretching techniques, and a strength and conditioning

problems associated with overuse injuries (Curtis, 1996). It has also been found that

preventative taping and splinting techniques can be used to prevent reinjury (Curtis, 1982).

Shoulder Pain

Shoulder pain is a common complaint among many athletes and nonathletes who

utilize a wheelchair (Schaefer & Proffer, 1989). Shoulder pain is not necessarily

considered an injury, but it can inhibit an athlete's mobility and upper body finctioning

(Nichols, Norman, & Ennis, 1979). During the propulsion phase of the wheelchair stroke

cycle, the arms and shoulders assume both weight bearing and locomotion characteristics

(Burnham, May, Nelson, Steadward, & Reid, 1993; Schaefer & Proffer, 1989). It has

been suggested that the major cause of shoulder pain is attributed to muscular imbalance.

Imbalances of the shoulder musculature may lead to impingement of the rotator cuff

muscles (infiaspinatus, supraspinatus, subscapularis, and teres minor), which can

potentially cause the athlete who uses a wheelchair great pain and discomfort (Burnham et

al., 1993).

Blisters

Blisters are the second most common injury seen among athletes who utilize a

wheelchair (Schaefer & Proffer, 1989). Most blisters occur on the hands and fingers and

are caused by excess fiction during all phases of the stroke cycle. Blisters can also occur

on the skin that contacts the seat post of the wheelchair. Although blisters may be

considered a minor injury, they can negatively impact performance.

Blister prevention techniques which include excess calloustformation, finger

taping, wearing gloves, and the use of padding over the seat post. area of the wheelchair

can help athletes optimize their athletic performanee. It has also been suggested that

wheelchair athletes wear a shirt between the skin and the wheelchair back (Ceccotti, 1984;

Madorsky & Curtis, 1984; Schaefer & Proffer, 1989).

Abrasions and Laceratiow

In Curtis and Dillon's (1985) survey, 17% @Gall injuries reported were due to

abrasions or lacerations. Bloomquist (1986) states that "Abrasions and lacerations may

occur when fingers or thumbs catch between wheelchairs or make contact with brakes,

push rims, or the metal edge on an empty arm rest socket" @. 98). Abrasions and

lacerations can also be caused by contact of the inner arms with the tires on the

downstroke of racing athietes (Curtis, 1982). In wheelchair marathon racing, abrasions

and lacerations can occur on the initial thrust of the start. The thumb may become caught

between the rim and the spoke of the wheelchair (Corcoran et al., 1980).

Prevention techniques include the removal of brakes, using arm rests or filing off

sockets for arm rests, and protection of the upper arm by using padding or clothing. For

wheelchair basketball players, it is suggested that the athlete camber, or bend the wheels

(Bloomquist, 1986; Ceccotti, 1984; Curtis, 1982; Madorsky & Curtis, 1984). Athletes

should cover sharp or protruding parts of their wheelchair with foam padding to prevent

injuries (Curtis, 1996).

Pressure Sores

Pressure sores, or decubitus ulcers, are caused by sitting in the same position for

prolonged periods of time. It should be noted, however, that pressure sores can

sometimes develop very quickly (Curtis, 1996). Ceccotti (1984) stated that these injuries

usually occur in young, novice athletes. Schaefer and Proffer (1989) established that

"...the critical period of pressure application is approximately two hours" @. 242).

Another cause of pressure sores is excessive perspiration accompanied by the shear forces

of wheelchair propulsion. Wheelchair design is also important for the prevention of

pressure sores. When the knees are higher than the buttocks, pressure is increased on the

buttocks, which may lead to pressure sores (Ceccotri, 1984).

Pressure sores can result in medical disqualification from participation in

wheelchair sports, therefore, prevention is important (Cormran et al., 1980). Padding

under the buttocks is most commonly recommended for pressure sore prevention. An

athlete's position in the wheelchair should be shifted frequently to change the force

distribution. Athletes should have their skin checked regularly by a trainer or coach to

detect pressure sore areas. Absorbent clothing will help prevent sores caused by

perspiration. Lastly, it is important that the athlete have good nutrition and hygiene.

Attention to all of these factors decrease the occurrence of pressure sores (Ceccotti, 1984;

Curtis, 1982; Curtis & Dion, 1985; Madorsky & Curtis 1984; Schaefer & Proffer, 1989).

Qnal Tunnel Syndromp

Carpal tunnel syndrome is a nerve compression injury. In wheelchair athletes, the

median nerve is compressed due to continual contact of the heel of the hand against the

rim of the wheel (Bloomquist, 1986; Ceccotti, 1984; Curtis & Dillon, 1985; Monahan,

1986; Weiss, 1986). This injury can also be caused by the pressure placed on the hands

during transfers or during shifting of body weight for pressure relief (Bloomquist, 1986;

Weiss, 1986). Symptoms of carpal tunnel syndrome include numbness and tingling, pain,

and weakness in the pronator muscles of the wrist. All of these symptoms occur in the

thumb and the second and thud phalanges, since they are innervated by the median nerve

(Ceccotti, 1984; Curtis & Dillon, 1985).

Prevention includes padded push rims and protective gloves. Splints designed

specifically for carpal tunnel syndrome can be used during the day and at night to help the

wrist relax. Muscle strengthening and good stroke techniques are important in

maintaining a healthy limb (Bloomquist, 1986; Ceccotti, 1984; Weiss, 1986). Curtis

(1996) suggested that "Changing the wheels contact point fiom the carpal tunnel to a

broader area of several fingers may decrease repetitive carpal tunnel trauma" (p, 18). If

symptoms persist, the athlete should seek medical evaluation and consider altering the

training regimen (Weiss, 1986).

then no re mi la to^ Disorders

Ceccotti (1984) stated that "Temperature regulation disorders from exposure to

heat or cold are predictable problems in the spinal cord injured person, since they lack

temperature control and sweating mechanisms" @. 29). The level of autonomic control an

athlete possesses is determined by the level of injury. Therefore, susceptibility to

thennoregulatory disorders differs among athletes (Armstrong et al., 1994; Madorsky &

Curtis, 1984; Schaefer & Proffer, 1989).

Hypotheda is a condition that is related to the loss of body heat. This becomes a

problem specifically in wheelchair marathoners and road racers. After a race, the heat

production of an athlete stops. If the wheelchair athlete is unable to shiver due to

autonomic impairment, the body is unable to properly cool down and the athlete

experiences rapid heat loss. Rapid cooling of the body can be prevented by wrapping the

athlete in an insulated blanket immediately following a race. The athlete should also

remove wet clothing and replace it with warm, dry clothing (Bloomquist, 1986; Corcoran

et al., 1980; Schaefer & Proffer, 1989).

Hyperthermia presents a greater risk to the wheelchair athlete than does

hypothermia. Hyperthermia occurs when the athlete has lost the ability to sweat or release

heat. Wheelchair athletes can rely only on sweatirlg fiom their arms, trunk, and head.

Quadriplegics do not sweat at all unless they are in a state of dysreflexia which is an

abnormal nerve or muscle condition marked by abnormal reflexes. A major cause of

hypertherrnia is dehydration. To prevent dehydration, athletes must make a conscious

effort to continually consume fluids throughout the competitive event and during training

sessions (Bloomquist, 1986; Mangus, 1988; Schaefer & Proffer, 1989).

Both conditions, hypothennia and hyperthermia, can be prevented by wearing

clothing appropriate for the ambient temperature, and being aware of the need for fluid

replacement. Hyperthermia can be prevented by using cold, wet towels to decrease body

temperature, and finding shady cool areas to rest during break periods (Madorsky &

Curtis, 1984; Schaefer & Proffer, 1989).

Prevention of Iniuries

Prevention of athletic injuries is a key to success for all athletes. Injury prevention

techniques include proper stretching, use ofa warm-up and cool down, and equipment

There are two purposes for stretching: improvement of flexibility and achieving fill

joint range of motion. Stretching should be done before and after a workout or trair~ing

session for the maximum benefits.

Warm-up. Warming-up is an important aspect of training. It allows the athlete's body to

begin muscular contraction, and it increases blood flow to the muscles. A good warm-up

may last from 10 to 15 minutes. The warm-up should begin slowly and gradually increase.

After the warm-up, the athlete can proceed with a stretching routine (Curtis, 1981).

Cool down. The cool down period allows the body to experience a period of less intense

exercise so that the muscles do not cramp. The cool down period can last anywhere from

5 to 10 minutes. After the cool down, athletes should perform their stretching routine

(Curtis, 1981).

Eauipment Modicationg

Recent design changes in sport wheelchairs have improved the athlete's efficiency

and made wheelchair sports much safer (Shephard, 1988). Footrests and seat heights have

been changed to provide better protection from leg injuries. The addition of seat padding

has prevented excessive pressure sores. Clothing has been designed to aid in the

absorption of sweat. Hazardous projections are removed from competitive chairs.

Wheels are cambered inwards. Unfortunately, some of these changes are very costly and

cannot be afforded by all athletes (Bloomquist, 1986; Ceccotti, 1984).

Sport S~ecific Research

Al~ine Ski Racers

McCormick (1985) specifically looked at injuries occurring in alpine skiing. He

found that the most common injury was to the knee. Other injuries included fractures,

contusions, lacerations, sprains, back injuries, fractured teeth, head injuries, and dislocated

shoulders. An injury found specific to skiing is an outrigger injury. Outriggers can cause

damage during a fall when the metal edges come in contact with the skier. McCormick

concluded that alpine ski racers with disabilities are susceptible to the same injuries as

nondisabled skiers.

Wheelchair Racing

Taylor and Williams (1995) examined the incidence of injuries to British individuals

who participated in wheelchair racing. They found that there was no diierence in the

frequency of injuries sustained by elite and nonelite racers, and that all participants were

equally likely to seek medical assistance for their injuries. There was a high occurrence of I

overuse injuries, although the authors did not indicate the specific joints involved. , I

I Wheelchair Marathow

I During the 1986 International Flower Marathon, Hoeberigs. Debets-Eggen, and 1

Debets (1990) conducted a study of the injuries that occurred during the event. Their

results indicate that skin abrasions, shoulder injuries, and elbow injuries were the most

I frequent. Other injuries included decubitus ulcers, upper arm injuries, and hand injuries.

Of the 60 athletes that competed in the marathon, 5 participants experienced thermal

stress.

Muscle Soreness in Wheelchair Basketball Plavers

I Hoeberigs and Verstappen (1984) conducted a study during the 1980 Paralympics

1 to determine the prevalence of muask soreness in wheelchair basketball players. This

study included teams fiom 16 nations. The results showed that 41% of the basketball

players that participated in the 1980 Paralympics experienced muscle soreness.

Summary of Related Literature

The majority of the research presented examined injuries commonly found among

athletes who use a wheelchair. The research also provided prevention techniques for these

injuries. The articles suggest that there are many ways to prevent athletic injuries fiom

occurring in wheelchair athletes. However, like any athletic event, injuries are bound to

happen.

e many studies have examined the types of injuries that occur in wheelchair

sports, few have investigated factors that may predispose one to injury. Taylor and

Wiiams (1995) began to look at these factors by comparing injury rates of elite and

nonelite athletes. While this is a beginning, more research needs to be completed in this

Lastly, several studies have looked at sport specific injuries. (Hoeherigs et al, 1990;

Hoeberigs & Verstappen, 1984; McConnick, 1985; Taylor & Williams, 1995). These

studies provide specific information on injuries that occur relative to the particular sport.

This enables a r ~ athlete or medical professional to pinpoint necessary information relative

to the athlete's event.

REFERENCES

Armstrong, L.B., Maresh, C.M., Riebe, D., Kenefick, R.W., Castellani, J.W., Senk, J.M., Echegaray, M., & Foley, M.F. (1994). Local cooling in wheelchair athletes during exercise-heat stress. MedicineandScience 21 1-216.

Bloomquist, L.E. (1986). Injuries to athletes with physical disabilities: Prevention implications. The Phvsic-(91, 97-105.

Burnham, R.S., May, L., Nelson, E., Steadward, R., & Reid, D.C. (1993). Shoulder pain in wheelchair athletes: The role of muscle imbalance. The American Journal gf Swrts Medicine. 21,238-242.

Ceccotti, F.S. (1984). Wheelchair sport injuries: An athletic training approach. Para~lepia - News. 38(2), 29-30.

Corcoran, P.J., Goldman, R.F., Hoerner, E.F., Kling, C., Knuttgen, H.G., Marquis, B., McCann, B.C., & Rossier, A.B. (1980). Sports medicine and the physiology of wheelchair marathon racing. Orthopedic Clinics of North America 11.697-716.

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Curtis, K.A. (1981). Wheelchair sportsmedicine, part 3: Stretching routines. Swrts 'N S~okes. 6.16-18.

Curtis, K.A. (1982). Wheelchair sportsmedicine, part 4: Athletic injuries. S~orts 'N Swkes. 7.20-24.

Curtis, K.A., & Dion, D.A. (1985). Survey of wheelchair athletic injuries: Common patterns and prevention. Para~lema 23,170-175.

Femara, M.S., & Davis, R.W. (1990). Injuries to elite wheelchair athletes. P w D ~ Z ~ ~ . 28,335-341.

Hoeberigs, J.H., & Verstappen, F.T. (1984). Muscle soreness in wheelchair basketballers. In a, 177-179.

Hoeberigs, J.H., Debets-Eggen, H.B.L., & Debets, P.M.L. (1990). Sports medical experiences fiom the International Flower Marathon for disabled wheelers. The American Jounral of S~orts Medicine. 18.418-421.

46

McCormick, D.P. (1985). Injuries in handicapped alpine ski racers. The Phvsiciw . . and Swrtsm~cme. 13(12), 93-97.

Madorsky, J.G., &, Curtis, K.A. (1984). Wheelchair sports medicine. The American Journal of SDORS Medicine. 12(2), 128-132.

Mangus, B.C. (1988). Medical care for wheelchair athletes. Adapted Phvsical -. 5.95.

Monahan, T. (1986). Wheelchair athletes need special treatment - but only for injuries. The Phvsician and Sportsmedicine. 14(7), 121-128.

Nichols, P.J., No- P.A, & Ennis. J.R. (1979). Wheelchair user's shoulder? Scandinavian Journal of Rehabiitative Medicine. ll,29-32.

Schaefer, RS., & Proffer, D.S. (1989). Sports medicine for wheelchair athletes, American Familv Phvsician 39(5), 239-245.

Shephard, RJ. (1988). Sports medicine and the wheelchair athlete. Sports Medicine. 4 226-249.

Taylor, D., &Williams, T. (1995). Sports injuries in athletes with disabiities: Wheelchair racing. P a r a ~ l e @ a 296-299.

Weiss, M. (1986). Carpal tunnel syndrome and other peripheral nerve problems in wheelchair sports. Two Bounce News. 7(4), 20-2i